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LETTER TO EDITOR
Year : 2012  |  Volume : 13  |  Issue : 1  |  Page : 51-52

Nikolsky's sign in staphylococcal scalded skin syndrome: A new diagnostic clue to the level of epidermal split


Consultant Dermatologist, Dermatology Unit, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka

Date of Web Publication23-Oct-2012

Correspondence Address:
Jayamini Seneviratne
Associate Professor in Dermatology, Lady Ridgeway Hospital for Children, Colombo 8
Sri Lanka
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Seneviratne J. Nikolsky's sign in staphylococcal scalded skin syndrome: A new diagnostic clue to the level of epidermal split. Indian J Paediatr Dermatol 2012;13:51-2

How to cite this URL:
Seneviratne J. Nikolsky's sign in staphylococcal scalded skin syndrome: A new diagnostic clue to the level of epidermal split. Indian J Paediatr Dermatol [serial online] 2012 [cited 2020 Jul 6];13:51-2. Available from: http://www.ijpd.in/text.asp?2012/13/1/51/102818

Sir,

Nikolsky's sign is an easily inducible and a valuable sign in clinical dermatology. This sign was first described in relation to pemphigusfoliaceous. [1],[2] Apart from intraepidermal blistering diseases, many other conditions in which the epidermal cell cohesion is weakened are likely to result in a positive Nikolsky's sign. Few additional signs and phenomena related to this sign have been described subsequently. These include the wet and dry Nikolsky's sign [3] and Nikolsky phenomenon. [4] However, hitherto, no sign had been described that is indicative of the level of epidermal split. Herein, I describe a new sign in relation to staphylococcal scalded skin syndrome (SSSS), recognized for the first time in a child of Sri Lankan origin.

A 4-year-old girl preferred to walk to our clinic in August this year with a history of fever and an erythematous rash involving the face. She had refused to be carried in view of the skin tenderness. Examination of her face revealed typical features of SSSS [Figure 1].
Figure 1: Staphylococcal scalded skin syndrome (SSSS) – Typical facial features

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With a gentle rub with the thumb, Nikolsky's sign was easily elicited on the back. Examination of the base of the erosion clearly showed the pigmented nature of the underlying skin [Figure 2].
Figure 2: SSSS-Nikolsky's sign

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In other words, this sign can be described as, "on elicitation of the Nikolsky's sign, if the underlying skin is pigmented then the split is upper epidermal."

Explanation of the Sign

The epidermolytic toxins A & B of certain phage types of Staphylococcus aureus, implicated in the pathogenesis of SSSS, are serine proteases. [5] These are known to cleave desmoglein 1, an essential transmembranous cadherin glycoprotein of the desmosomes. As desmoglein 1 is extensively expressed in the superficial layers of the epidermis, the main effect of the toxin would be an intraepidermal split between the granular and spinous layers. [6] The underlying spinous cell layers with the epidermal melanin units are unaffected. Once the weakened upper epidermal layers are peeled off, as in Nikolsky's sign, the pigmented spinous cell layer is easily visualized. This sign naturally will be more conspicuous in pigmented skin and help to differentiate, clinically, SSSS from toxic epidermal necrolysis (TEN) [Figure 3], another serious acute illness in which the Nikolsky's sign can be easily elicited. However, in TEN, there is widespread apoptotic cell death of keratinocytes, including the basal cell layer. Therefore, on elicitation of the Nikolsky's sign, the inflamed upper dermis could be seen.
Figure 3: Toxic epidermal necrolysis

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  References Top

1.Lever WF. Phemphigus. Medicine 1953:32:1-123.  Back to cited text no. 1
    
2.Lever WF. Pemphigus and pemphigoid. Springfield, IL: Charles C Thomas; 1965.  Back to cited text no. 2
    
3.Salopekct G. Nikolsky's sign: Is it 'dry' or is it 'wet'? Br J Dermatol 1997;136:762-7.  Back to cited text no. 3
    
4.Braun-Falco O, Plewig G, Wolff HH, Winkelmann RK, editors. Vesicular and bullous disease. Dermatology. Berlin: Springer- Verlag; 1991. p. 467-501.  Back to cited text no. 4
    
5.Dancer JD, GarratR, Saldanha J. Theepidermolytic toxins are serine protease. FEBSLett 1990;268:129-32.  Back to cited text no. 5
    
6.Burns T, Stephen Breathnach Neil Cox, Christopher Griffiths Anatomy and organization of human skin Rook's textbook of Dermatology. Wiley Blackwell Vol 1 page 3.22  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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